- Review Article
- Open Access
Deep venous stenting in females
CVIR Endovascular volume 6, Article number: 14 (2023)
Deep venous stenting has gained increasing prominence in recent years. This issue focuses on special considerations in female patients. The specific challenge relates to the fact that these patients are often much younger than those in whom arterial stents are placed. The stents have to perform adequately over potentially 60 years- and there is no data of that length available.
Indications for venous stenting include: Table 1 (Breen, 2020; de Graaf et al., 2013; Mussa et al., 2007; Hartung et al., 2009):
Acute and chronic venous obstruction.
To alleviate symptoms of pelvic venous obstructive disease.
In the treatment of venous stenosis in patients with recurrent lower extremity varicose veins.
Acute and chronic venous obstruction have been extensively dealt with elsewhere, but deserve some mention here (Mahnken et al., 2014; Seager et al., 2016; Editor's Choice – European Society for Vascular Surgery (ESVS), 2022; O’Sullivan, n.d.). Females of childbearing years are at increased risk of venous thrombo-embolic disease, not just from pregnancy and the puerperium, but also from the oral contraceptive pill (OCP). OCP is usually regarded as a “permissive” rather than a “causative” factor (de Bastos et al., 2014). A common combination appears to be the OCP and a stenotic lesion e.g. Iliac Vein Compression Syndrome (May-Thurner) (Narayan et al., 2012; O'Sullivan et al., 2000). Once the thrombus has been dissolved/removed, an underlying stenotic lesion is frequently revealed. The likelihood of finding a lesion depends on the intensity and accuracy of the search for it; so good quality CTV or MRV pre op and IVUS intra-op (see below) are the preferred options (O’Halloran N, Lehane C, O. Malley E, O’Sullivan GJ. (n.d.) Iliac vein lesions are frequently missed by radiologists on cross sectional imaging leading to delays in diagnosis. (CVIR submitted)). Assuming a lesion is found then it needs to be dealt with by means of a stent. Angioplasty on its own is rarely sufficient (Patel et al., 2000).
The remainder of the article deals with the other patient groups. Pelvic venous disease in women has attracted increasing significance (Bałabuszek et al., 2022; Sulakvelidze et al., 2021; Tanaka et al., 2021), and a proportion of these patients have an underlying deep venous stenosis. Venous stents may be indicated in some patients. However, this area is contentious as there are no hard and fast diagnostic rules to decide which patients merit stent placement. Many of these patients are young, and the stent must stay open, in position, and not fracture- for up to 50 years.
Diagnostic methods, pre-operative approach
A thorough, detailed history and focused physical examination are mandatory before considering venous stent placement (Tanaka et al., 2021). Accurate cross-sectional imaging is also essential to improve patient selection. Practitioners can employ Ultrasound, CT venography, and MR venography as initial diagnostic methods (Zucker et al., 2016; Coelho & O'Sullivan, 2019; Coelho & O'Sullivan, 2020). Focused questions are required on walking distance, presence or absence of venous claudication, weight gain, gravitational pain (pain which is worse in the evenings rather than the mornings), post-coital pain (not occurring immediately but it can last for several hours after coitus), urinary symptoms, the number of pregnancies, recurrent spontaneous abortion, use of the oral contraceptive pill and occasionally, irritable bowel type symptoms (Tanaka et al., 2021; Khilnani, 2022; Latthe et al., 2006; Leatherby et al., 2020; Meissner et al., 2021; Beard et al., 1988). The pain is usually absent upon awakening, but starts with upright activity in the morning. Although it is often characterized as “non-cyclic pain”, it may worsen around ovulation and menses to a variable extent. Perform the initial clinical examination with the patient standing. With appropriate consent, photographs of external sequelae, including venous hypertensive change, varicose veins, vulvar varicosities, or venous ulceration, are helpful. Lower extremity varicose veins which occur in an atypical pattern should alert the physician to the possibility of a pelvic source (Fig. 1- posterior thigh varices- taken with patient permission).
Often patients are referred by a gynaecologist or urologist; their imaging will reflect this; if they have seen a gynaecologist, they will usually have undergone either a transabdominal or transvaginal ultrasound which may demonstrate pelvic varices. Occasionally the varices will have been demonstrated on laparoscopy, but a negative laparoscopy report is not helpful (Steenbeek et al., 2018; Baekgaard et al., 2017).
Depending on availability, either a non-oral contrast post IV contrast-enhanced CT abdomen and pelvis to below the lesser trochanters or combined MRA/MR venography is performed; the latter is preferable as it does not employ radiation nor intravenous contrast (Baekgaard et al., 2017). MRA is necessary as late arterial shunting of blood is seen patients with relux; standard MRV may miss this. In addition, using phase-encoded MRV, the flow direction, specifically in the gonadal veins, can be evaluated; we have found this to be very helpful in identifying which veins are likely to require embolization (Dick et al., 2010; Meneses et al., 2011; Asciutto et al., 2008).
Unlike in arterial disease, there are no set criteria for identifying which patients have a causative venous stenosis on MRV/CTV. Normal ranges have been established (Arendt et al., 2020), but these suffer from a lack of uniformity of the degree of pre-scan hydration, and whether the scan is performed on inspiration, expiration, or Valsalva. This lack of standardisation may have indirectly led to the recent increase in venous stent insertion and subsequent migration (Sayed et al., 2022); or in the case of dehydration before scanning, a false negative scan and potential under-treatment.
Pressure measurements are of proven benefit in arterial disease (Kinney & Rose, 1996) but less so in deep venous (Mahnken et al., 2014). The gradients are small, and the real issue is the ambulatory venous pressure differential (Kurstjens et al., 2016) as opposed to recumbent non-ambulatory venous pressures.
Regardless of the site of access to the deep venous system (internal jugular, femoral, etc.), a combination of venography and intravascular ultrasound is ideal for evaluating the deep veins. Intravascular ultrasound is of proven benefit in more accurate identification of lesions which are missed on venography. Venography is better at demonstrating collaterals, the flow velocity, and the rate of contrast washout; however, it is less sensitive to identifying stenosis, particularly smooth, gradual stenosis rather than abrupt focal lesions (Neglén & Raju, 2002; McLafferty, 2012; Montminy et al., 2019; Gagne et al., 2018). Fasting patients are all relatively dehydrated, and this may flatten the “reference segment” of the iliac vein, and lead to calculating falsely low percentage stenosis on IVUS. These patients are best served by 2 l 0.9 NACL IV pre procedure and continued hydration support (author’s experience SJS).
Ideally both venography and intravascular ultrasound are performed on every patient. There is currently no randomised control trial to demonstrate which is more likely to yield a successful outcome in pelvic venous disorders. Although IVUS is a very accurate method of identifying venous stenosis, a significant proportion of our readers may not have access to it. IVUS has been approved for coverage in the United States, but this has not been extended worldwide. The cost of the console and catheters is a factor. An alternative (but again, one without a randomised control trial), is the passage of a gently inflated (< 1 atm) 14 mm balloon through the iliac veins; if no “catch” or hold up to the passage of balloon is felt, it is unlikely that there is a significant stenosis. Therefore, a combination of these three methods may be employed to verify the existence of venous stenosis.
Venous stents specifically in pelvic venous disorders
Patients with both pelvic vein congestion syndrome, and those who develop recurrent varicose veins may have an underlying non-thrombotic iliac vein lesion (NIVL). It is essential to identify those patients who will benefit from venous stenting. There has been a scarcely credible rise in the performance of venous stenting, and it is difficult to believe that all of it is clinically justified. Patients may have a combination of venous stenosis (in the renal vein or common iliac vein), and reflux (into the gonadal veins and internal iliac veins). Which procedure should you perform first; and in what order? Some experts have shown benefit from iliac vein stent placement on its own, while others have shown that pelvic vein embolisation alone results in a high proportion of clinical relief (De Gregorio et al., 2020; Lakhanpal et al., 2021; Harris, 2021). A variety of factors may be at play here; including the age of the patient, their gravid status, and whether they also have varicose veins in the legs (Sulakvelidze et al., 2021).
Based on fairly large series, it appears that both iliac vein stent placement and pelvic vein embolization performed individually, have no effect on subsequent pregnancy rates (Liu et al., 2019; Dos Santos et al., 2017). There is no data to confirm that this is the case if performed concurrently. In patient with both reflux and iliac vein obstruction, and no desire to retain fertility, then performing pelvic vein embolisation and venous stent placement at the same time, makes sense. In a patient who may wish to become pregnant subsequently there is no data to support which treatment should be performed first, or whether they should be performed together. Therefore, patients need to have appropriately consented before the procedure. It will also change the post-operative management as the patient will likely require some degree of anticoagulation if a venous stent is placed. Finally, venous stent placement typically causes low back pain for a variable duration (Snow et al., 2023), and this may affect the type of anticoagulation used as non-steroidal medications may interact with both Warfarin and newer oral anticoagulant (NOACS).
Again, it must be borne in mind that many of these patients are young, and the stent will need to stay open and in position (no migration, fracture or thrombosis), for upwards of 50 years. Venous stents have been in existence for a maximum of 35 years; there is no published data with this degree of longevity. Therefore, it is not a trivial decision, and is very different to placing an arterial stent in a 70-year-old arteriopath with at most 15 years of life expectancy.
The final potential indication for venous stenting is postural orthostatic tachycardia syndrome (POTS) and dysautonomia (Ormiston 2022; Knuttinen et al., 2021; Lum et al., 2012)- this is an entirely new and exciting area of research. In a way, it is linked to the realisation that lack of venous return to the right atrium may have profound and unrecognized effects on general well-being (Morris et al., 2020; Smith et al., 2022). It is known that many conditions of unknown cause have been shown to involve impaired orthostatic blood return from the lower body, which may be associated with Ehlers-Danlos syndrome. This may trigger compensatory effects including sympathetic overdrive and high circulating nor-epinephrine, and other problems including interstitial cystitis, chronic bowel problems, migraines, hip pain, excess sweating. A detailed discussion is beyond the scope of this summary, but a cascade of effects may reach many different body systems. There is no evidence that pelvic venous intervention in the absence of pelvic pain is indicated for these other conditions at this time, but this is a possible future research objective (Taylor, 1949; Neĭmark & Shelkovnikova, 2012; Mack et al., 2010; Roma et al., 2018; Chelimsky et al., 2016; Whitehead et al., 2002; Shelkey et al., 2013; Santoshi 2018).
The technique of venous stent placement
In contra-distinction to iliac or aortic work, where the common femoral artery is the most common route of access, the common femoral vein should best be avoided in all forms of pelvic venous or ilio-caval venous stent placement. This is because the disease process may often extend down close to the common femoral venous CFV puncture point; the worst-case situation is when a stent should ideally be placed across the actual CFV access point.
For acute iliofemoral deep vein thrombosis, popliteal vein access is preferred. If thrombosed, we employ catheter-directed thrombolysis –or ultrasound-accelerated thrombolysis. If the popliteal vein is open, a single session, mechanical or pharmaco-mechanical thrombectomy may be the best option (O'Sullivan, 2011). Following thrombus removal/dissolution, the proximal stenosis is uncovered; usually, this lesion requires stent placement.
For chronic iliofemoral venous reconstruction or venous stenting as part of pelvic venous disorders, a jugular or mid-femoral route of access is typically chosen. Once the lesion is crossed, and venography/IVUS is performed, balloon angioplasty is required. Typically, we use a 16 mm balloon at high pressure, greater than 20 atm in the common iliac vein and 14 mm in the external iliac vein, and perhaps 12 mm in the common femoral vein. It should be possible to judge which is the dominant inflow in cases of chronic iliofemoral venous occlusion utilising CTV-MRV (Coelho & O'Sullivan, 2019); IVUS will confirm. Following balloon angioplasty, a stent of appropriate length and diameter is chosen; typically, diameters of 16 mm in the common iliac vein, 14 mm in the external iliac vein and common femoral vein are chosen. The stent is positioned to cover the stenosis but avoiding the ostium of the contra-lateral common iliac venous inflow (Bajwa et al., 2019). Stents need to extend from areas with good flow to good flow (normal to normal) (O'Sullivan et al., 2007). Following stent placement, repeat balloon angioplasty is performed again to the nominal diameter of the stent at the same atmospheric pressure as pre-stent placement. If IVUS is available, it is used to confirm that the stent is fully expanded and that there are no synechiae at the inferior end of the stent, particularly if the common femoral venous inflow is compromised (Neglén & Raju, 2002; McLafferty, 2012). Finally, venography is performed, which should demonstrate rapid, in-line flow through the stented segment, with the abolition of collaterals, as confirmation of stent expansion is more accurately assessed by employing intravascular ultrasound.
Choice of stent
There are no randomised controlled trials comparing different types of venous stents. The Food and Drug Administration (FDA) mandated trials were set up to evaluate safety and efficacy comparing them with a previous meta-analysis (Razavi et al., 2015). Effectively they were designed to ensure the stents could be commercially available (Murphy et al., 2022; Dake et al., 2021; Hofmann et al., 2023). The physical properties of stents have been evaluated (Dabir et al., 2018); however, at the time of writing, two of the seven stents assessed in that publication are not on the market, and other stents have since received CE mark. Factors to consider include gaps between the interstices so as not to block inflow from side branches (e.g. larger gaps in “Z” stents (Cook Medical, Bloomington, IN, USA), flexibility, degree of foreshortening, radial resistive force etc. No trials exist to compare these, and no recommendations for stent choice in a specific situation are anything beyond personal feeling and experience. There is no evidence that covered stents confer any advantage over bare stents in routine situations.
Post-operative imaging and follow-up management
Following venous stent placement, MRV is of limited value, as even modern “dedicated” venous Nitinol stents usually contain a small proportion of a ferromagnetic substance which causes signal dropout. Therefore, neither patency nor in-stent restenosis can be identified. Colour Doppler ultrasound (CDUS) is the mainstay for follow-up, but in obese patients, contrast-enhanced CT venography (CTV) may be a reasonable method also. There is marked variation in anticoagulation and antiplatelet management after stenting for non-thrombotic pelvic venous stenosis (Notten et al., 2021).
A recent Delphi consensus among physicians active in venous stenting suggested that anticoagulation is preferred to antiplatelet therapy for the first 6 to 12 months after stenting. At the same time, low-molecular-weight heparin (LMWH) is the first-choice anticoagulant in the first 2 to 6 weeks post-stenting (Milinis et al., 2018). These recommendations may not apply to young female patients at low risk for venous thromboembolism. We typically use LMWH for 2 weeks, followed by a novel oral anticoagulant (NOAC) for 10 weeks. Clinical review at 2 months with CDUS, and symptomatically after that.
Complications of venous stenting (Razavi et al., 2015).
Fistula formation to adjacent structures.
Acute AV fistula.
Management of these complications is expectant- in other words, complication-specific. Stent fracture did not occur with any degree of frequency in the stent trials (Murphy et al., 2022; Dake et al., 2021; Hofmann et al., 2023). Stent migration is rare if the appropriate diameter and length stent is used (Sayed et al., 2022).
Acute thrombosis is usually managed by venous thrombectomy; chronic stent thrombosis may be more challenging. Rupture and fistula formation both appear to be quite rare unless there has been previous arterial or venous surgery which disrupts the integrity of the surrounding sheath. Acute arterio-venous fistula has been described in conditions where the retroperitoneum is extremely fibrotic.
Venous stenting is growing in impact in a variety of disease states. Indications include venous stenosis and obstruction, to alleviate pelvic pain, and to improve venous return in disparate conditions. Accurately assessing the clinical significance for any specific degree of degree of obstruction is more challenging than in arteries; and pressure measurements are of little use. This review highlights the importance of this treatment in females.
Availability of data and materials
Computed Tomographic venography
Magnetic Resonance Venography
atmospheres (of pressure)
Colour Doppler UltraSound
Low Molecular Weight Heparin
Novel Oral Anticoagulant
non thrombotic iliac vein lesion
postural orthostatic tachycardia syndrome
Arendt VA, Mabud TS, Jeon GS, An X, Cohn DM 3rd, Fu JX, Hofmann LV (2020) Analysis of patent, unstented lower extremity vein segment diameters in 266 patients with venous disease. J Vasc Surg Venous Lymphat Disord 8(5):841–850. https://doi.org/10.1016/j.jvsv.2019.12.078. Epub 2020 Feb 24. PMID: 32107163
Asciutto G, Mumme A, Marpe B, Köster O, Asciutto KC, Geier B (2008) MR venography in the detection of pelvic venous congestion. Eur J Vasc Endovasc Surg 36(04):491–496
Baekgaard N, Fanelli F, O'Sullivan, GJ. (2017). New horizons in deep venous disease management. 9–788877-118936
Bajwa R, Bergin D, O'Sullivan GJ (2019) Aiming for the bottom corner: how to score a field goal when landing venous stents in may-Thurner syndrome. J Vasc Interv Radiol 30(10):1555–1561. https://doi.org/10.1016/j.jvir.2019.04.033. Epub 2019 Aug 27. PMID: 31471189
Bałabuszek K, Toborek M, Pietura R (2022) Comprehensive overview of the venous disorder known as pelvic congestion syndrome. Ann Med 54(1):22–36. https://doi.org/10.1080/07853890.2021.2014556. PMID: 34935563; PMCID: PMC8725876
Beard RW, Reginald PW, Wadsworth J (1988) Clinical features of women with chronic lower abdominal pain and pelvic congestion. Br J Obstet Gynaecol 95:153–161. https://doi.org/10.1111/j.1471-0528.1988.tb06845.x
Breen K (2020) Role of venous stenting for venous thromboembolism. Hematology Am Soc Hematol Educ Program 2020(1):606–611. https://doi.org/10.1182/hematology.2020000147. PMID: 33275696; PMCID: PMC7727585
Chelimsky G, Simpson P, McCabe N, Zhang L, Chelimsky T (2016) Autonomic testing in women with chronic pelvic pain. J Urol 196(2):429–434
Coelho A, O'Sullivan GJ (2019) Usefulness of direct computed tomography venography in predicting inflow for venous reconstruction in chronic post-thrombotic syndrome. Cardiovasc Intervent Radiol 42(5):677–684. https://doi.org/10.1007/s00270-019-02161-5. Epub 2019 Jan 9. PMID: 30627773
Coelho A, O'Sullivan GJ (2020) Evaluation of incidence and clinical significance of obturator hook sign as a marker of chronic iliofemoral venous outflow obstruction in computed tomography venography. J Vasc Surg Venous Lymphat Disord 8(2):237–243. https://doi.org/10.1016/j.jvsv.2019.07.011. Epub 2019 Nov 5. PMID: 31699665
Contemporary Endovascular Therapies in Treatment of Acute Iliofemoral Deep Vein Thrombosis (CLEAR-DVT). Clinical Trials Identifier NCT03901872
Dabir D, Feisst A, Thomas D, Luetkens JA, Meyer C, Kardulovic A, Menne M, Steinseifer U, Schild HH, Kuetting DLR (2018) Physical properties of venous stents: An experimental comparison. Cardiovasc Intervent Radiol 41(6):942–950. https://doi.org/10.1007/s00270-018-1916-1. Epub 2018 Feb 28. PMID: 29492633
Dake MD, O'Sullivan G, Shammas NW, Lichtenberg M, Mwipatayi BP, Settlage RA; VERNACULAR Trial Investigators (2021) Three-Year Results from the Venovo Venous Stent Study for the Treatment of Iliac and Femoral Vein Obstruction. Cardiovasc Intervent Radiol 44(12):1918–1929. https://doi.org/10.1007/s00270-021-02975-2. Epub 2021 Sep 20. Erratum in: Cardiovasc Intervent Radiol. 2021: PMID: 34545448; PMCID: PMC8451739
de Bastos M, Stegeman BH, Rosendaal FR, Van Hylckama Vlieg A, Helmerhorst FM, Stijnen T, Dekkers OM (2014) Combined oral contraceptives: venous thrombosis. Cochrane Database Syst Rev (3):CD010813. https://doi.org/10.1002/14651858.CD010813.pub2. PMID: 24590565
de Graaf R, Arnoldussen C, Wittens CH (2013) Stenting for chronic venous obstructions a new era. Phlebology. 28(suppl 1):117–122
De Gregorio MA, Guirola JA, Alvarez-Arranz E et al (2020) Pelvic venous disorders in women due to pelvic varices: treatment by embolization: experience in 520 patients. J Vasc Interv Radiol 31:1560–1569. https://doi.org/10.1016/j.jvir.2020.06.017
Dick EA, Burnett C, Anstee A, Hamady M, Black D, Gedroyc WM (2010) Time-resolved imaging of contrast kinetics three-dimensional (3D) magnetic resonance venography in patients with pelvic congestion syndrome. Br J Radiol 83(994):882–887. https://doi.org/10.1259/bjr/82417499. PMID: 20846985; PMCID: PMC3473747
Dos Santos SJ, Holdstock JM, Harrison CC, Whiteley MS (2017) The effect of a subsequent pregnancy after transjugular coil embolisation for pelvic vein reflux. Phlebology 32(1):27–33. https://doi.org/10.1177/0268355515623898. Epub 2016 Jul 9. PMID: 26769721
Editor's Choice – European Society for Vascular Surgery (ESVS) (2022) Clinical practice guidelines on the Management of Chronic Venous Disease of the lower limbs De Maeseneer, Marianne G.ESVS guidelines committee, document reviewers, et al. Eur J Vasc Endovasc Surg 63(2):184–267
Gagne PJ, Gasparis A, Black S, Thorpe P, Passman M, Vedantham S, Marston W, Iafrati M (2018) Analysis of threshold stenosis by multiplanar venogram and intravascular ultrasound examination for predicting clinical improvement after iliofemoral vein stenting in the VIDIO trial. J Vascular Surg: Venous Lymphatic Disord. 6(1): 48–56.e1, ISSN 2213-333X, https://doi.org/10.1016/j.jvsv.2017.07.009
Gasparis AP, Kim PS, Dean SM, Khilnani NM, Labropoulos N (2020) Diagnostic approach to lower limb edema. Phlebology 35(9):650–655. https://doi.org/10.1177/0268355520938283. Epub 2020 Jul 6. PMID: 32631171; PMCID: PMC7536506
Harris LM (2021) Obstruction or reflux as the primary problem in pelvic congestion syndrome. J Vasc Surg Venous Lymphat Disord. 9(5):1199. https://doi.org/10.1016/j.jvsv.2021.03.016 PMID: 34399939
Hartung O, Loundou AD, Barthelemy P, Arnoux D, Boufi M, Alimi YS (2009) Endovascular management of chronic disabling Ilio-caval obstructive lesions: long-term results. Eur J Vasc Endovasc Surg 38(1):118–124
Hofmann LR, Gagne P, Brown JA, Saunders A, Comerota A; VIVO Study Investigators (2023) 12-month endpoint results from the evaluation of the Zilver vena venous stent in the treatment of symptomatic Iliofemoral venous outflow obstruction (VIVO clinical study). J Vasc Surg Venous Lymphat Disord S2213-333X(23)00006–9. https://doi.org/10.1016/j.jvsv.2022.12.066. Epub ahead of print. PMID: 36646383
Khilnani NM. et al. (2022) Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel Journal of Vascular and Interventional Radiology, Volume 30, Issue 6, 781–789 Smith SJ, Sichlau M, Sewall LE, et al. An online survey of pelvic congestion support group members regarding comorbid symptoms and syndromes. Phlebology. 37(8):596–601. https://doi.org/10.1177/02683555221112567
Kinney TB, Rose SC (1996) Intraarterial pressure measurements during angiographic evaluation of peripheral vascular disease: techniques, interpretation, applications, and limitations. Am J Roent 166:277–284
Knuttinen MG, Zurcher KS, Khurana N, Patel I, Foxx-Orenstein A, Harris LA, Lawrence A, Aguilar F, Sichlau M, Smith BH, Smith SJ (2021) Imaging findings of pelvic venous insufficiency in patients with postural orthostatic tachycardia syndrome. Phlebology. 36(1):32–37. https://doi.org/10.1177/0268355520947610. Epub 2020 Aug 5. PMID: 32757696
Kurstjens RL, de Wolf MA, Konijn HW, Toonder IM, Nelemans PJ, de Graaf R, Wittens CH (2016) Intravenous pressure changes in patients with postthrombotic deep venous obstruction: results using a treadmill stress test. J Thromb Haemost. 14(6):1163–1170. https://doi.org/10.1111/jth.13333. Epub 2016 May 31. PMID: 27061685
Lakhanpal G, Kennedy R, Lakhanpal S, Sulakvelidze L, Pappas PJ (2021) Pelvic venous insufficiency secondary to iliac vein stenosis and ovarian vein reflux treated with iliac vein stenting alone. J Vasc Surg Venous Lymphat Disord 9(5):1193–1198. https://doi.org/10.1016/j.jvsv.2021.03.006. Epub 2021 Mar 18. PMID: 33746048
Latthe P, Latthe M, Say L et al (2006) WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health 6:177. https://doi.org/10.1186/1471-2458-6-177
Leatherby RJ, Harries P, Shah SS (2020) The management of pelvic congestion syndrome - a word of caution. J Obstet Gynaecol 40:283–284. https://doi.org/10.1080/01443615.2019.1599333
Liu J, Han L, Han X (2019) The effect of a subsequent pregnancy after ovarian vein embolization in patients with infertility caused by pelvic congestion syndrome. Acad Radiol 26(10):1373–1377. https://doi.org/10.1016/j.acra.2018.12.024. Epub 2019 Jan 17. PMID: 30660471
Lum YW, Brooke BS, Arnaoutakis GJ, Williams TK, Black JH 3rd (2012) Endovascular procedures in patients with Ehlers-Danlos syndrome: a review of clinical outcomes and iatrogenic complications. Ann Vasc Surg 26(1):25–33. https://doi.org/10.1016/j.avsg.2011.05.028. Epub 2011 Sep 23. PMID: 21945330
Mack KJ, Johnson JN, Rowe PC (2010) Orthostatic intolerance and the headache patient. Semin Pediatr Neurol 17(2):109–116
Mahnken AH, Thomson K, de Haan M, O'Sullivan GJ (2014) CIRSE standards of practice guidelines on iliocaval stenting. Cardiovasc Intervent Radiol;37(4):889–897. https://doi.org/10.1007/s00270-014-0875-4. Epub 2014 Mar 15. PMID: 24633533
McLafferty RB (2012) The role of intravascular ultrasound in venous thromboembolism. Semin Intervent Radiol 29(1):10–15. https://doi.org/10.1055/s-0032-1302446. PMID: 23450229; PMCID: PMC3348758
Meissner MH, Khilnani NM, Labropoulos N, et al. The symptoms-varices-pathophysiology (SVP) classification of pelvic venous disorders a report of the American Vein & Lymphatic Society international working group on pelvic venous disorders. J Vasc Surg Venous Lymphat Disord Published online January 30, 2021. https://doi.org/10.1016/j.jvsv.2020.12.084
Meneses LQ, Uribe S, Tejos C, Andía ME, Fava M, Irarrazaval P (2011) Using magnetic resonance phase-contrast velocity mapping for diagnosing pelvic congestion syndrome. Phlebology. 26(04):157–161
Milinis K, Thapar A, Shalhoub J, Davies AH (2018) Antithrombotic therapy following venous stenting: international Delphi consensus. Eur J Vasc Endovasc Surg 55(04):537–544
Montminy ML, Thomasson JD, Tanaka GL, Lamanilao LM, Crim W, Raju S (2019) A comparison between intravascular ultrasound and venography in identifying key parameters essential for iliac vein stenting. J Vascular Surg: Venous Lymphatic Disord 7(6):801–807, ISSN 2213-333X, https://doi.org/10.1016/j.jvsv.2019.03.015
Morris RI, Sobotka PA, Balmforth PK, Stöhr EJ, McDonnell BJ, Spencer D, O'Sullivan GJ, Black SA (2020) Iliocaval venous obstruction, cardiac preload reserve and exercise limitation. J Cardiovasc Transl Res 13(4):531–539. https://doi.org/10.1007/s12265-020-09963-w Epub 2020 Feb 10. PMID: 32040765; PMCID: PMC7423854
Murphy E, Gibson K, Sapoval M, Dexter DJ, Kolluri R, Razavi M, Black S (2022) Pivotal Study Evaluating the Safety and Effectiveness of the Abre Venous Self-Expanding Stent System in Patients With Symptomatic Iliofemoral Venous Outflow Obstruction. Circ Cardiovasc Interv 15(2):e010960. https://doi.org/10.1161/CIRCINTERVENTIONS.121.010960. Epub 2022 Feb 2. PMID: 35105153; PMCID: PMC8843393
Mussa FF, Peden EK, Zhou W, Lin PH, Lumsden AB, Bush RL (2007) Iliac vein stenting for chronic venous insufficiency. Tex Heart Inst J 34(1):60–66 4
Narayan A, Eng J, Carmi L, McGrane S, Ahmed M, Sharrett AR, Streiff M, Coresh J, Powe N, Hong K (2012) Iliac vein compression as risk factor for left- versus right-sided deep venous thrombosis: case-control study. Radiology 265(3):949–957. https://doi.org/10.1148/radiol.12111580. PMID: 23175547; PMCID: PMC3504322
Neglén P, Raju S (2002) Intravascular ultrasound scan evaluation of the obstructed vein. J Vasc Surg 35(4):694–700. https://doi.org/10.1067/mva.2002.121127 PMID: 11932665
Neĭmark AI, Shelkovnikova NV (2012) [Endovascular treatment of persistent dysuria and chronic pelvic pain in women with pelvic varicose veins]. Urologiia (Moscow, Russia: 1999). 2012;4(04):20–24.(4):20–4. [cited 2020 Nov 24] Available from: https://pubmed.ncbi.nlm.nih.gov/23116017/
Notten P, Ten Cate H, Ten Cate-Hoek AJ (2021) Postinterventional antithrombotic management after venous stenting of the iliofemoral tract in acute and chronic thrombosis: A systematic review. J Thromb Haemost 19(3):753–796. https://doi.org/10.1111/jth.15197. Epub 2021 Jan 5. PMID: 33249698; PMCID: PMC7986750
O’Sullivan, Gerard J. et al Thrombolysis and Iliofemoral Vein Stent Placement in Cancer Patients with Lower Extremity Swelling Attributed to Lymphedema. J Vascular Interventional Radiol 26(1):39–459
Ormiston CK, Padilla E, Van DT, Boone C, You S, Roberts AC, Hsiao A, Taub PR (2022) May-Thurner syndrome in patients with postural orthostatic tachycardia syndrome and Ehlers-Danlos syndrome: a case series. Eur Heart J Case Reports 6(4): ytac161. https://doi.org/10.1093/ehjcr/ytac161
O'Sullivan GJ (2011) The role of interventional radiology in the management of deep venous thrombosis: advanced therapy. Cardiovasc Intervent Radiol 34(3):445–461. https://doi.org/10.1007/s00270-010-9977-9. Epub 2010 Oct 7. PMID: 20927522
O'Sullivan GJ, Lohan DA, Cronin CG, Delappe E, Gough NA (2007) Stent implantation across the ostia of the renal veins does not necessarily cause renal impairment when treating inferior vena cava occlusion. J Vasc Interv Radiol 18(7):905–908. https://doi.org/10.1016/j.jvir.2007.03.007 PMID: 17609452
O'Sullivan GJ, Semba CP, Bittner CA, Kee ST, Razavi MK, Sze DY, Dake MD (2000) Endovascular management of iliac vein compression (may-Thurner) syndrome. J Vasc Interv Radiol 11(7):823-36. https://doi.org/10.1016/s1051-0443(07)61796-5. PMID: 10928517
O'Sullivan GJ, Waldron D, Mannion E, Keane M, Donnellan PP (2015) Thrombolysis and iliofemoral vein stent placement in cancer patients with lower extremity swelling attributed to lymphedema. J Vasc Interv Radiol 26(1):39–45. https://doi.org/10.1016/j.jvir.2014.10.010 PMID: 25541444
Patel NH, Stookey KR, Ketcham DB, Cragg AH (2000) Endovascular management of acute extensive iliofemoral deep venous thrombosis caused by may-Thurner syndrome. J Vasc Interv Radiol 11(10):1297-302. https://doi.org/10.1016/s1051-0443(07)61304-9. PMID: 11099239
Raju S, Owen S Jr, Neglen P (2002) The clinical impact of iliac venous stents in the management of chronic venous insufficiency. J Vasc Surg 35:8–15. https://doi.org/10.1067/mva.2002.121054
Razavi MK, Jaff MR, Miller LE (2015) Safety and effectiveness of stent placement for Iliofemoral venous outflow obstruction: systematic review and Meta-analysis. Circ Cardiovasc Interv 8(10):e002772. https://doi.org/10.1161/CIRCINTERVENTIONS.115.002772. PMID: 26438686
Roma M, Marden CL, De Wandele I, Francomano CA, Rowe PC (2018) Postural tachycardia syndrome and other forms of orthostatic intolerance in Ehlers-Danlos syndrome. Auton Neurosci 215:89–96
Santoshi RKN, Lakhanpal S, Satwah V et al (2018) Iliac vein stenosis is an underdiagnosed cause of pelvic venous insufficiency. J Vasc Surg Venous Lymphat Disord. 6:202–211. https://doi.org/10.1016/j.jvsv.2017.09.007
Sayed MH, Salem M, Desai KR, O'Sullivan GJ, Black SA (2022) A review of the incidence, outcome, and management of venous stent migration. J Vasc Surg Venous Lymphat Disord 10(2):482–490. https://doi.org/10.1016/j.jvsv.2021.07.015. Epub 2022 Jan 11. PMID: 35026448
Seager MJ, Busuttil A, Dharmarajah B, Davies AH (2016) Editor's choice – a systematic review of Endovenous stenting in chronic venous disease secondary to iliac vein obstruction. Eur J Vasc Endovasc Surg 51(1):100–120, ISSN 1078-5884. https://doi.org/10.1016/j.ejvs.2015.09.002
Shelkey J, Huang C, Karpa K, Singh H, Silvis M (2013) Case report: pelvic congestion syndrome as an unusual etiology for chronic hip pain in 2 active, middle-aged women. Sports Health: A Multidisciplinary Approach 6(2):145–148
Smith SJ, Sichlau SJ, Sewall LE, Smith BH, Chen B, Khurana N, Rowe PC (2022) An online survey of Pelvic Congestion Syndrome Support Group members regarding Co-morbid Symptoms and Syndromes. 2022. [E-Pub. Vol 0–0] Phlebology 37 (8): 596–601. https://pubmed.ncbi.nlm.nih.gov/35831253/
Snow C, Pappas S, Sulakvelidze L, Kennedy R, Lakhanpal S, Pappas PJ. Nitinol stents placed in iliac veins are not associated with prolonged back pain. Phlebology. 2023;38(1):44–50. https://doi.org/10.1177/02683555221142710. Epub 2022 Nov 28. PMID: 36440624
Steenbeek MP, van der Vleuten CJM, Schultze Kool LJ, Nieboer TE (2018) Noninvasive diagnostic tools for pelvic congestion syndrome: a systematic review. Acta Obstet Gynecol Scand 97:776–786
Sulakvelidze L, Tran M, Kennedy R, Lakhanpal S, Pappas PJ (2021) Presentation patterns in women with pelvic venous disorders differ based on age of presentation. Phlebology 36(2):135–144. https://doi.org/10.1177/0268355520954688. Epub 2020 Sep 1. PMID: 32869695
Tanaka ME, Kutsenko O, Salazar G (2021) Choosing the Most appropriate treatment option for pelvic venous disease: stenting versus embolization. Semin Intervent Radiol 38(2):182–188. https://doi.org/10.1055/s-0041-1727104 Epub 2021 Jun 3. PMID: 34108804; PMCID: PMC8175116
Taylor HC (1949) Vascular congestion and hyperemia. Am J Obstet Gynecol 57(2):211–230
Vedantham S, Goldhaber SZ, Julian JA, Kahn SR, Jaff MR, Cohen DJ, Magnuson E, Razavi MK, Comerota AJ, Gornik HL, Murphy TP, Lewis L, Duncan JR, Nieters P, Derfler MC, Filion M, Gu CS, Kee S, Schneider J, Saad N, Blinder M, Moll S, Sacks D, Lin J, Rundback J, Garcia M, Razdan R, VanderWoude E, Marques V, Kearon C (2017) ATTRACT trial investigators. Pharmacomechanical catheter-directed thrombolysis for deep-vein thrombosis. N Engl J Med 377(23):2240–2252. https://doi.org/10.1056/NEJMoa1615066 PMID: 29211671; PMCID: PMC5763501
Whitehead WE, Palsson O, Jones KR (2002) Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications? Gastroenterology. 122(4):1140–1156
Zucker EJ, Ganguli S, Ghoshhajra BB, Gupta R, Prabhakar AM (2016) Imaging of venous compression syndromes. Cardiovasc Diagn Ther 6(6):519–532. https://doi.org/10.21037/cdt.2016.11.19. PMID: 28123973; PMCID: PMC5220205
Ethics approval and consent to participate
Consent for publication
GJOS is on the speakers’ bureau for Cook Medical, BSCI, BD, and Medtronic; and is a paid scientific advisor for these companies as well as Philips, Whiteswell, Creganna, Veinway, Microbot, and Surmodics.
SJS has no competing issues.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
O’Sullivan, G., Smith, S. Deep venous stenting in females. CVIR Endovasc 6, 14 (2023). https://doi.org/10.1186/s42155-023-00354-1